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Albacker T, Tash A, Alamri H, Alasnag M, Alkashkari W, Almutairi F, Alqoofi F, Alsaileek A, Aluthman U, Alzahrani G, Balghith M, Makhdom F. Saudi Heart Association/National Heart Center/Saudi Arabian Cardiac Interventional Society/Saudi Society for Cardiac Surgeons/Saudi Cardiac Imaging Group 2023 TAVI Guidelines. J Saudi Heart Assoc 2024; 36:184-231. [PMID: 39234557 PMCID: PMC11373420 DOI: 10.37616/2212-5043.1379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/15/2024] [Accepted: 05/28/2024] [Indexed: 09/06/2024] Open
Abstract
Saudi Arabia has seen a significant improvement in its healthcare system over the past four decades resulting in an increase in life-expectancy. Transcatheter aortic valve implantation (TAVI) has spread widely in Saudi Arabia and has become a routine procedure in many centers. The expanding clinical indications and the availability of the technology have made it possible for many large and intermediate centers all over the country to commence their own TAVI programs. So, the aim of this document is to standardize TAVI practices in different Saudi Arabian centers through reasonable guidelines based on the evaluation and summarization of the best available evidence. The review committee, composed of different experts in several aspects of the management of patient undergoing TAVI, based their recommendations on the reviewed and analyzed evidence and the class and level of recommendations were discussed until a consensus was reached by the panel.
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Affiliation(s)
- Turki Albacker
- Cardiac Sciences Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- King Fahad Cardiac Center, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Adel Tash
- National Heart Center, Saudi Health Council, Saudi Arabia
| | | | - Mirvat Alasnag
- Cardiac Center, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Wail Alkashkari
- King Abdulaziz Medical City - Jeddah and King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Saudi Arabia
| | - Fawaz Almutairi
- King Abdulaziz Medical City - Riyadh and King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Saudi Arabia
| | | | - Ahmed Alsaileek
- King Abdulaziz Medical City - Riyadh and King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Saudi Arabia
| | - Uthman Aluthman
- King Faisal Specialist Hospital and Research Centre, Saudi Arabia
| | | | - Mohammed Balghith
- King Abdulaziz Medical City - Riyadh and King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Saudi Arabia
| | - Fahd Makhdom
- Imam Abdul Rahman Bin Faisal University, Saudi Arabia
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Fallahtafti P, Soleimani H, Ebrahimi P, Ghaseminejad‐Raeini A, Karimi E, Shirinezhad A, Sabri M, Mehrani M, Taheri H, Siegel R, Shah N, Nanna M, Hakim D, Hosseini K. Comparative Analysis of PCI Strategies in Aortic Stenosis Patients Undergoing TAVI: A Systematic Review and Network Meta-Analysis. Clin Cardiol 2024; 47:e24324. [PMID: 39054901 PMCID: PMC11272956 DOI: 10.1002/clc.24324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 07/02/2024] [Accepted: 07/08/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) has been increasingly used in patients with severe aortic stenosis (AS). Since coronary artery disease (CAD) is common among these patients, it is crucial to choose the best method and timing of revascularization. This study aims to compare different timing strategies of percutaneous coronary intervention (PCI) in patients with severe AS undergoing TAVI to clarify whether PCI timing affects the patients' outcomes or not. METHODS A frequentist network meta-analysis was conducted comparing three different revascularization strategies in patients with CAD undergoing TAVI. The 30-day all-cause mortality, in-hospital mortality, all-cause mortality at 1 year, 30-day rates of myocardial infarction (MI), stroke, and major bleeding, and the need for pacemaker implantation at 6 months were analyzed in this study. RESULTS Our meta-analysis revealed that PCI during TAVI had higher 30-day mortality (RR = 2.46, 95% CI = 1.40-4.32) and in-hospital mortality (RR = 1.70, 95% CI = [1.08-2.69]) compared to no PCI. Post-TAVI PCI was associated with higher 1-year mortality compared to other strategies. While no significant differences in major bleeding or stroke were observed, PCI during TAVI versus no PCI (RR = 3.63, 95% CI = 1.27-10.43) showed a higher rate of 30-day MI. CONCLUSION Our findings suggest that among patients with severe AS and CAD undergoing TAVI, PCI concomitantly with TAVI seems to be associated with worse 30-day outcomes compared with no PCI. PCI after TAVI demonstrated an increased risk of 1-year mortality compared to alternative strategies. Choosing a timing strategy should be individualized based on patient characteristics and procedural considerations.
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Affiliation(s)
- Parisa Fallahtafti
- Tehran Heart Center, Cardiovascular Disease Research InstituteTehran University of Medical SciencesTehranIran
- School of MedicineTehran University of Medical SciencesTehranIran
| | - Hamidreza Soleimani
- Tehran Heart Center, Cardiovascular Disease Research InstituteTehran University of Medical SciencesTehranIran
| | - Pouya Ebrahimi
- Tehran Heart Center, Cardiovascular Disease Research InstituteTehran University of Medical SciencesTehranIran
| | | | - Elaheh Karimi
- Tehran Heart Center, Cardiovascular Disease Research InstituteTehran University of Medical SciencesTehranIran
- School of MedicineTehran University of Medical SciencesTehranIran
| | | | - Mahshad Sabri
- Tehran Heart Center, Cardiovascular Disease Research InstituteTehran University of Medical SciencesTehranIran
| | - Mehdi Mehrani
- Tehran Heart Center, Cardiovascular Disease Research InstituteTehran University of Medical SciencesTehranIran
| | - Homa Taheri
- Smidt Heart InstituteCedars‐Sinai Medical CenterLos AngelesCaliforniaUSA
| | - Robert Siegel
- Smidt Heart InstituteCedars‐Sinai Medical CenterLos AngelesCaliforniaUSA
| | - Neeraj Shah
- Independence Health estmoreland HospitalGreensburgPennsylvaniaUSA
| | - Michael Nanna
- Section of Cardiovascular MedicineYale University School of MedicineNew HavenCTUSA
| | - Diaa Hakim
- Brigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Kaveh Hosseini
- Tehran Heart Center, Cardiovascular Disease Research InstituteTehran University of Medical SciencesTehranIran
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Sakurai Y, Yokoyama Y, Fukuhara S, Takagi H, Kuno T. Complete transcatheter versus surgical approach to aortic stenosis with coronary artery disease: A systematic review and meta-analysis. J Thorac Cardiovasc Surg 2024; 167:1305-1313.e9. [PMID: 36150940 DOI: 10.1016/j.jtcvs.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 07/24/2022] [Accepted: 08/15/2022] [Indexed: 10/15/2022]
Abstract
OBJECTIVE This meta-analysis aimed to evaluate outcomes of transcatheter aortic valve replacement (TAVR) with percutaneous coronary intervention (PCI) versus surgical aortic valve replacement (SAVR) with coronary artery bypass grafting (CABG). METHODS The MEDLINE, EMBASE, and Cochrane Library databases were searched through November 2021 to identify studies comparing TAVR + PCI and SAVR + CABG for severe aortic stenosis with concurrent coronary artery disease. Outcomes of interest were all-cause mortality, repeat coronary intervention, rehospitalization, myocardial infarction, and stroke during follow-up, and 30-day periprocedural outcomes. RESULTS Two randomized controlled trials and 6 observational studies including a total of 104,220 patients (TAVR + PCI, n = 5004; SAVR + CABG, n = 99,216) were included. The weighted mean follow-up period was 30.2 months. TAVR + PCI was associated with greater all-cause mortality and coronary reintervention during follow-up period (hazard ratio, 1.35; 95% confidence interval [CI], 1.11-1.65; P = .003, hazard ratio, 4.14; 95% CI, 1.74-9.86; P = .001, respectively), 30-day permanent pacemaker implantation rate (odds ratio [OR], 3.79; 95% CI, 1.61-8.95; P = .002), and periprocedural vascular complications (OR, 6.97; 95% CI, 1.85-26.30; P = .004). In contrast, TAVR + PCI was associated with a lower rate of 30-day acute kidney injury (OR, 0.32; 95% CI, 0.20-0.50; P = .0001). Rehospitalization, myocardial infarction, stroke during follow-up, and other periprocedural outcomes including 30-day mortality were similar in both groups. CONCLUSIONS In patients with severe aortic stenosis and coronary artery disease, TAVR + PCI was associated with greater all-cause mortality at follow-up compared with SAVR + CABG. Heart Team approach to assess TAVR candidacy remains imperative.
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Affiliation(s)
- Yosuke Sakurai
- Department of Surgery, Marshall University Joan Edwards School of Medicine, WVa
| | - Yujiro Yokoyama
- Department of Surgery, St Luke's University Health Network, Pa
| | - Shinichi Fukuhara
- Department of Cardiothoracic Surgery, University of Michigan, Ann Arbor, Mich
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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Del Portillo JH, Farjat-Pasos J, Galhardo A, Avvedimento M, Mas-Peiro S, Mengi S, Nuche J, Mohammadi S, Rodés-Cabau J. Aortic Stenosis With Coronary Artery Disease: SAVR or TAVR-When and How? Can J Cardiol 2024; 40:218-234. [PMID: 37758014 DOI: 10.1016/j.cjca.2023.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/10/2023] [Accepted: 09/19/2023] [Indexed: 10/03/2023] Open
Abstract
The growing number of candidates for transcatheter aortic valve replacement (TAVR) has increased the interest in the concomitant presence of coronary artery disease (CAD) and severe aortic stenosis (AS), prompting the need to define the appropriate revascularization strategy for each case. The reported prevalence of concurrent AS and CAD has varied over the years on the basis of the CAD definition and the population evaluated. Revascularization for treating CAD in patients with severe AS involves additional interventions that could impact outcomes. The addition of coronary artery bypass grafting (CABG) to surgical aortic valve replacement (SAVR) has demonstrated favourable effects on long-term prognosis, while the impact of adding percutaneous coronary intervention (PCI) to TAVR may depend on the CAD complexity and the feasibility of achieving complete or reasonably incomplete revascularization. Furthermore, the comparison between SAVR+CABG and TAVR+PCI in low-intermediate surgical risk and low-intermediate complex CAD patients did not reveal differences in all-cause mortality or stroke between the groups. However, there is some evidence showing a lower incidence of major cardiovascular events with the SAVR+CABG strategy for patients with complex CAD. Thus, SAVR+CABG seems to be the best option for patients with low-intermediate surgical risk and complex CAD, and TAVR+PCI for high surgical risk patients seeking complete and/or reasonable incomplete revascularization. After deciding between TAVR+PCI or SAVR+CABG, factors such as timing for PCI, low ejection fraction, coronary reaccess, and valve durability must be considered. Finally, alternative methods for assessing CAD severity are currently under evaluation to ascertain their real value for guiding revascularization in patients with severe AS with CAD.
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Affiliation(s)
| | - Julio Farjat-Pasos
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Attilio Galhardo
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Marisa Avvedimento
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Silvia Mas-Peiro
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Siddhartha Mengi
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Jorge Nuche
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Siamak Mohammadi
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.
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Spiliopoulos K, Magouliotis D, Angelis I, Skoularigis J, Kemkes BM, Salemis NS, Athanasiou T, Gansera B, Xanthopoulos AV. Concomitant Valve Replacement and Coronary Artery Bypass Grafting Surgery: Lessons from the Past, Guidance for the Future? A Mortality Analysis in 294 Patients. J Clin Med 2023; 13:238. [PMID: 38202244 PMCID: PMC10780271 DOI: 10.3390/jcm13010238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/24/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024] Open
Abstract
OBJECTIVE The aims of this study were to analyze parameters influencing early and late mortality after concomitant valve replacement and coronary artery bypass grafting surgery, using early and long-term information from an institutionally available data registry, and to discuss the results in relation to the current treatment strategies and perspectives. METHODS The study population consisted of 294 patients after combined valve replacement with mechanical prosthesis and CABG surgery. RESULTS There were 201 men (68.4%) and 93 women (31.6%). Concurrent to the coronary artery bypass grafting, 238 patients (80.9%) underwent aortic-, 46 patients (15.6%) mitral- and 10 patients (3.4%) doublevalve replacement. Cumulative duration of follow up was 1007 patient-years (py) with a maximum of 94 months and was completed in 92.2% (271 cases). Overall hospital mortality (30 days) rate was 6.5% (n = 19). It was significantly higher in patients of female gender, older than 70 y, in those suffering preoperative myocardial infarction, presenting with an additive EuroScore > 8 and being hemodynamically unstable after the operation. Cumulative survival rate at 7.6 y was 78.6%. Determinants of prolonged survival were male gender, age at operation < 70 y, preoperative sinus rhythm, normal renal function, additive EuroScore < 8 and the use of internal thoracic artery for grafting. Subsequent multivariate analysis revealed preoperative atrial fibrillation (HR: 2.1, 95% CI: 0.82-5.44, p: 0.01) and risk group of ES > 8 (HR: 3.63, 95% CI: 1.45-9.07, p < 0.01) as independent predictors for lower long-term survival. CONCLUSIONS Hospital mortality (30 d) was nearly 2.5-fold higher in female and/or older than 70 y patients. Preoperative atrial fibrillation and/ or a calculated ES > 8 were independent predisposing factors of late mortality for combined VR and CABG surgery. Tailoring the approach, with the employment of the newest techniques and hybrid procedures, to the individual patient clinical profile enables favorable outcomes for concomitant valvular disease and CAD, especially in high-risk patients.
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Affiliation(s)
- Kyriakos Spiliopoulos
- Department of Cardiothoracic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41500 Larissa, Greece; (D.M.); (T.A.)
- Department of Cardiovascular Surgery, Klinikum Bogenhausen, 81925 Munich, Germany (B.G.)
| | - Dimitrios Magouliotis
- Department of Cardiothoracic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41500 Larissa, Greece; (D.M.); (T.A.)
| | - Ilias Angelis
- Department of Cardiovascular Surgery, Klinikum Bogenhausen, 81925 Munich, Germany (B.G.)
| | - John Skoularigis
- Department of Cardiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41500 Larissa, Greece; (J.S.); (A.V.X.)
| | - Bernhard M. Kemkes
- Department of Cardiovascular Surgery, Klinikum Bogenhausen, 81925 Munich, Germany (B.G.)
| | | | - Thanos Athanasiou
- Department of Cardiothoracic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41500 Larissa, Greece; (D.M.); (T.A.)
| | - Brigitte Gansera
- Department of Cardiovascular Surgery, Klinikum Bogenhausen, 81925 Munich, Germany (B.G.)
| | - Andrew V. Xanthopoulos
- Department of Cardiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41500 Larissa, Greece; (J.S.); (A.V.X.)
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Elderia A, Gerfer S, Eghbalzadeh K, Adam M, Baldus S, Rahmanian P, Kuhn E, Wahlers T. Surgical versus Interventional Treatment of Concomitant Aortic Valve Stenosis and Coronary Artery Disease. Thorac Cardiovasc Surg 2023; 71:620-631. [PMID: 36549305 DOI: 10.1055/a-2003-2105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Coronary artery disease (CAD) is frequently diagnosed in patients with aortic valve stenosis. Treatment options include surgical and interventional approaches. We therefore analyzed short-term outcomes of patients undergoing either coronary artery bypass grafting with simultaneous aortic valve replacement (CABG + AVR) or staged percutaneous coronary intervention and transcatheter aortic valve implantation (PCI + TAVI). METHODS From all patients treated since 2017, we retrospectively identified 237 patients undergoing TAVI within 6 months after PCI and 241 patients undergoing combined CABG + AVR surgery. Propensity score matching was performed, resulting in 101 matched pairs. RESULTS Patients in the CABG + AVR group were younger compared with patients in the PCI + TAVI group (71.9 ± 4.9 vs 81.4 ± 3.6 years; p < 0.001). The overall mortality at 30 days before matching was higher after CABG + AVR than after PCI + TAVI (7.8 vs 2.1%; p = 0.012). The paired cohort was balanced for both groups regarding demographic variables and the risk profile (age: 77.2 ± 3.7 vs78.5 ± 2.7 years; p = 0.141) and EuroSCORE II (6.2 vs 7.6%; p = 0.297). At 30 days, mortality was 4.9% in the CABG + AVR group and 1.0% in the PCI + TAVI group (p = 0.099). Rethoracotomy was necessary in 7.9% in the CABG + AVR, while conversion to open heart surgery was necessary in 2% in the PCI + TAVI group. The need for new pacemaker was lower after CABG + AVR than after PCI + TAVI (4.1 vs 6.9%; p = 0.010). No paravalvular leak (PVL) was noted in the CABG + AVR group, while the incidence of moderate-to-severe PVL after PCI + TAVI was 4.9% (p = 0.027). CONCLUSION A staged interventional approach comprises a short-term survival advantage compared with combined surgery for management of CAD and aortic stenosis. However, PCI + TAVI show a significantly higher risk of atrioventricular block and PVL. Further long-term trials are warranted.
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Affiliation(s)
- Ahmed Elderia
- Department of Cardiothoracic Surgery, University of Cologne, Heart Center, Cologne, Germany
| | - Stephen Gerfer
- Department of Cardiothoracic Surgery, University of Cologne, Heart Center, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, University of Cologne, Heart Center, Cologne, Germany
| | - Matti Adam
- Department of Cardiology, University of Cologne, Heart Center, Cologne, Germany
| | - Stephan Baldus
- Department of Cardiology, University of Cologne, Heart Center, Cologne, Germany
| | - Parwis Rahmanian
- Department of Cardiothoracic Surgery, University of Cologne, Heart Center, Cologne, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, University of Cologne, Heart Center, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University of Cologne, Heart Center, Cologne, Germany
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Ullah W, Sarvepalli D, Kumar A, Zahid S, Saleem S, Muhammadzai HZU, Khattak F, Block PC, Jaber WA, Shishehbor MH, Filby SJ, Devireddy C. Trends and outcomes of combined percutaneous (TAVI+PCI) and surgical approach (SAVR+CABG) for patients with aortic valve and coronary artery disease: A National Readmission Database (NRD) analysis. Catheter Cardiovasc Interv 2023; 102:946-957. [PMID: 37698396 DOI: 10.1002/ccd.30832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND In patients with severe aortic stenosis (AS) and concomitant severe coronary artery disease (CAD), the relative merits of a combined percutaneous (transcatheter aortic valve implantation [TAVI] and percutaneous coronary intervention [PCI]] versus surgical approach (surgical aortic valve replacement [SAVR] and coronary artery bypass graft [CABG]) remain unknown. AIMS To determine the utility of combined percutaneous versus surgical approaches in patients with severe AS and CAD. METHODS The National Readmission Database (NRD) (2015-2019) was queried to identify all cases of TAVI+PCI and SAVR+CABG. The adjusted odds ratios (aOR) of mortality, stroke, and its composite (major adverse cardiovascular events [MACE]) were calculated using a propensity-score matched (PSM) analysis. RESULTS A total of 89,314 (5358 TAVI+PCI, 83,956 SAVR+CABG) patients were included in the crude analysis. There was a gradual increase in the utilization of TAVI+PCI from 2016 to 2019 by 2%-4% per year. Using PSM, a subset of 11,361 (5358 TAVI+PCI, 6003 SAVR+CABG) patients with a balanced set of demographics and baseline comorbidities was selected. During index hospitalization, the adjusted odds of MACE (aOR 0.72, 95% confidence interval [CI] 0.62-0.83), and all-cause mortality (aOR 0.68, 95% CI 0.57-0.81) were significantly lower in patients undergoing TAVI+PCI compared with SAVR+CABG. However, patients undergoing TAVI+PCI had a higher incidence of MACE (aOR 1.40, 95% CI 1.05-1.87), and mortality (aOR 1.75, 95% CI 1.22-2.50) at 30-days. The risk of index-admission (aOR 0.82, 95% CI 0.62-1.09) and 30-day (aOR 0.88, 95% CI 0.51-1.51) stroke was similar between the two groups. CONCLUSION In selected patients with severe AS and concomitant CAD, a combined percutaneous approach (TAVR+PCI) compared with SAVR+CABG may confer a lower risk of MACE and mortality during index admission but a higher incidence of 30-day complications.
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Affiliation(s)
- Waqas Ullah
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | - Arnav Kumar
- Brigham and Women's Hospital Heart & Vascular Center, Boston, Massachusetts, USA
| | - Salman Zahid
- Rochester General Hospital, Rochester, New York, USA
| | - Sameer Saleem
- University of Kentucky, Bowling Green, Kentucky, USA
| | | | - Furqan Khattak
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Peter C Block
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Wissam A Jaber
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mehdi H Shishehbor
- University Hospitals Harrington Heart and Vascular Institute, Cleveland, Ohio, USA
| | - Steven J Filby
- University Hospitals Harrington Heart and Vascular Institute, Cleveland, Ohio, USA
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Miazza J, Vasiloi I, Koechlin L, Gahl B, Santer D, Berdajs D, Nestelberger T, Kaiser C, Eckstein F, Reuthebuch O. Combining Minimally Invasive Direct Coronary Artery Bypass Grafting with Transapical Aortic Valve Implantation-The Next Level Heart Team Approach. J Clin Med 2023; 12:6890. [PMID: 37959355 PMCID: PMC10647604 DOI: 10.3390/jcm12216890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/23/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023] Open
Abstract
We present the results of a combined approach for transapical aortic valve replacement and minimally invasive coronary artery bypass grafting (taTAVI-MIDCAB) in patients with combined aortic stenosis and coronary artery disease. BACKGROUND For patients presenting with aortic stenosis and coronary artery disease, a simultaneous procedure addressing both diseases is recommended to reduce operative risk. In high-risk patients with hostile femoral or coronary axis, taTAVI-MIDCAB can be an alternative minimally invasive approach, offering the benefits of left interior mammary artery to left anterior descending coronary artery (LIMA-LAD) grafting. METHODS From 2014 to 2022, 10 patients underwent taTAVI-MIDCAB for combined coronary and severe aortic stenosis in the hybrid operation theater at our institution. We assessed perioperative outcomes and follow-up outcomes. RESULTS The median age was 83 years (81 to 86). The procedure was successfully performed in all patients without conversion to sternotomy. The median length of hospital and intensive care unit stay was 9 days (7 to 16) and 2.5 days (1 to 5), respectively. The median flow over the coronary artery bypass was 31 (22 to 44) mL/min, with a pulsatility index (PI) of 2.4 (2.1 to 3.2). Mild paravalvular leak occurred in 2 patients (10%). There were no neurological events nor acute kidney injury. Pacemaker implantation was required in 1 patient (10%). CONCLUSIONS Simultaneous surgical coronary revascularization and interventional valve implantation in the setting of a hostile femoral and coronary axis appears to be safe and beneficial.
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Affiliation(s)
- Jules Miazza
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland; (J.M.); (D.S.)
| | - Ion Vasiloi
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland; (J.M.); (D.S.)
| | - Luca Koechlin
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland; (J.M.); (D.S.)
| | - Brigitta Gahl
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland; (J.M.); (D.S.)
| | - David Santer
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland; (J.M.); (D.S.)
| | - Denis Berdajs
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland; (J.M.); (D.S.)
| | - Thomas Nestelberger
- Department of Cardiology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland
| | - Christoph Kaiser
- Department of Cardiology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland
| | - Friedrich Eckstein
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland; (J.M.); (D.S.)
| | - Oliver Reuthebuch
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland; (J.M.); (D.S.)
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9
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An KR, Gaudino MFL. How should we manage complex coronary disease during transcatheter aortic valve implantation? Indian J Thorac Cardiovasc Surg 2023; 39:568-569. [PMID: 37885928 PMCID: PMC10597952 DOI: 10.1007/s12055-023-01573-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 06/30/2023] [Accepted: 07/03/2023] [Indexed: 10/28/2023] Open
Affiliation(s)
- Kevin R. An
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 E 68Th St, New York, NY 10065 USA
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, ON Canada
| | - Mario F. L. Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 E 68Th St, New York, NY 10065 USA
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10
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Oyoshi T, Mitsuta Y, Uemura Y, Tajima K, Hirata N. Anesthetic management with remimazolam in very elderly patients undergoing hybrid surgery of transcatheter aortic valve implantation plus off-pump coronary artery bypass grafting: report of two cases. JA Clin Rep 2023; 9:69. [PMID: 37878210 PMCID: PMC10600062 DOI: 10.1186/s40981-023-00662-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND Remimazolam is a short-acting benzodiazepine with small circulatory depression. We used remimazolam for general anesthesia management in two very elderly patients undergoing hybrid surgery of transcatheter aortic valve implantation (TAVI) plus off-pump coronary artery bypass grafting (OPCABG). CASE PRESENTATION A 96-year-old man (case 1) and a 92-year-old woman (case 2) had complex coronary artery disease (CAD) and severe aortic stenosis (AS) and were scheduled for TAVI plus OPCAB. Anesthesia in both patients was induced with 6 mg/kg/h remimazolam and fentanyl and maintained with 0.3 mg/kg/h and 0.5 mg/kg/h remimazolam and fentanyl, respectively. Although catecholamines were required, we successfully maintained circulation during the induction of anesthesia and the procedures of OPCAB and TAVI. Both patients were discharged without complications. CONCLUSION Remimazolam can be a useful option for safe general anesthesia in very elderly patients when performing hybrid surgery.
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Affiliation(s)
- Takafumi Oyoshi
- Department of Anesthesiology, Kumamoto University, Graduate School of Medical Sciences, Kumamoto, Japan.
| | - Yuki Mitsuta
- Department of Anesthesiology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Yumiko Uemura
- Department of Anesthesiology, Minamata City General Hospital and Medical Center, Kumamoto, Japan
| | - Koichiro Tajima
- Department of Anesthesiology, Kumamoto University, Graduate School of Medical Sciences, Kumamoto, Japan
| | - Naoyuki Hirata
- Department of Anesthesiology, Kumamoto University, Graduate School of Medical Sciences, Kumamoto, Japan
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11
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Guo Y, Zhang W, Wu H. Percutaneous versus surgical approach to aortic valve replacement with coronary revascularization: A systematic review andmeta-analysis. Perfusion 2023:2676591231178894. [PMID: 37224394 DOI: 10.1177/02676591231178894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE The optimal treatment of patients with severe aortic stenosis (AS) and complex coronary artery disease (CAD) remains controversial. We conducted a meta-analysis to investigate outcomes of transcatheter aortic valve replacement (TAVR) with percutaneous coronary intervention (PCI) versus surgical aortic valve replacement (SAVR) with coronary artery bypass grafting (CABG). METHODS We searched PubMed, Embase, and Cochrane databases from its inception up to 17 December 2022 for studies that assessed TAVR + PCI versus SAVR + CABG in patients with AS and CAD. The primary outcome was perioperative mortality. RESULTS Six observational studies including 135,003 patients assessing TAVI + PCI (n = 6988) versus SAVR + CABG (n = 128,015) were included. Compared to SAVR + CABG, TAVR + PCI was not significantly associated with perioperative mortality (RR, 0.76; 95% CI, 0.48-1.21; p = 0.25), vascular complications (RR, 1.85; 95% CI, 0.72-4.71; p = 0.20), acute kidney injury (RR, 0.99; 95% CI, 0.73-1.33; p = 0.95), myocardial infraction (RR, 0.73; 95% CI, 0.30-1.77; p = 0.49), or stroke (RR, 0.87; 95% CI, 0.74-1.02; p = 0.09). TAVR + PCI significantly reduced the incidence of major bleeding (RR, 0.29; 95% CI, 0.24-0.36; p < 0.01) and length of hospital stay (MD, -1.60; 95% CI, -2.45 to -0.76; p < 0.01), but increased the incidence of pacemaker implantation (RR, 2.03; 95% CI, 1.88-2.19; p < 0.01). At follow-up, TAVR + PCI was significantly associated with coronary reintervention (RR, 3.17; 95% CI, 1.03-9.71; p = 0.04) and a reduced rate of long-term survival (RR, 0.86; 95% CI, 0.79-0.94; p < 0.01). CONCLUSIONS In patients with AS and CAD, TAVR + PCI did not increase perioperative mortality, but increased the rates of coronary reintervention and long-term mortality.
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Affiliation(s)
- Yujian Guo
- Department of Graduate School, Changzhi Medical College, Changzhi, Shanxi, China
| | - Wei Zhang
- Department of Cardiothoracic Surgery, Changzhi People's Hospital, Changzhi, Shanxi, China
| | - Haibo Wu
- Department of Cardiothoracic Surgery, Changzhi People's Hospital, Changzhi, Shanxi, China
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12
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Lérault A, Villecourt A, Decottignies-Dienne T, Tassan-Mangina S, Heroguelle V, Di Cesare A, Rubin S, Ruggieri VG, Metz D, Faroux L. Catheter versus surgical approach for the management of concomitant aortic stenosis and coronary artery disease: An inverse probability treatment weighting analysis. Arch Cardiovasc Dis 2023; 116:117-125. [PMID: 36702719 DOI: 10.1016/j.acvd.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 12/09/2022] [Accepted: 12/12/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Two therapeutic strategies are available when aortic stenosis and coronary artery disease coexist: a transcatheter approach, with percutaneous coronary intervention followed by transcatheter aortic valve replacement; and a surgical approach, consisting of surgical aortic valve replacement combined with coronary artery bypass graft. AIM We sought to compare the outcomes of these two strategies. METHODS The study population consisted of 241 patients who benefited from aortic valve replacement and coronary revascularization (transcatheter, n=150; surgery, n=91). RESULTS Patients in the transcatheter population were older (83.5 vs. 71.8years; P<0.001) and had a higher Logistic EuroSCORE (11.1% vs. 5.7%; P<0.001). At 30days postprocedure, patients who had surgery exhibited more life-threatening bleedings (12.1% vs 4.5%; P=0.034), acute kidney injury (12.1% vs. 1.3%; P<0.001) and atrial fibrillation (55.6% vs. 8.7%; P<0.001). After a median follow-up of 27months, the risk of major adverse cardiovascular or cerebrovascular events did not differ significantly between the two strategies (hazard ratio [HR] 1.41, 95% confidence interval [CI] 0.97-2.04; P=0.07), whereas estimated glomerular filtration rate<60mL/min (HR 2.22, 95% CI 1.58-3.12; P<0.001), peripheral artery disease (HR 2.00, 95% CI 1.37-2.91; P<0.001) and left ventricular ejection fraction<50% (HR 1.69, 95% CI 1.12-2.55; P=0.012) were associated with a negative prognosis. CONCLUSIONS In our study, patients with aortic stenosis and coronary artery disease treated by catheter were older and had a higher co-morbidity burden than those treated by surgery. The surgical strategy was associated with a higher rate of 30-day complications, but long-term outcomes were similar between the two strategies.
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Affiliation(s)
- Adèle Lérault
- Department of Cardiology, Reims University Hospital, 51092 Reims, France
| | | | | | | | | | | | - Sylvain Rubin
- Cardiac Surgery Department, Reims University Hospital, 51092 Reims, France
| | | | - Damien Metz
- Department of Cardiology, Reims University Hospital, 51092 Reims, France
| | - Laurent Faroux
- Department of Cardiology, Reims University Hospital, 51092 Reims, France; EA3801 HERVI, SFR CAP Santé, University of Reims Champagne Ardenne, 51100 Reims, France.
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13
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Dhingra NK, Verma S, Yanagawa B, Hibino M. Complete transcatheter versus complete surgical management for combined aortic stenosis and coronary artery disease: A false dichotomy? J Card Surg 2022; 37:2084-2085. [DOI: 10.1111/jocs.16531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/01/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Nitish K. Dhingra
- Division of Cardiac Surgery, St. Michael's Hospital University of Toronto Toronto Ontario Canada
| | - Subodh Verma
- Division of Cardiac Surgery, St. Michael's Hospital University of Toronto Toronto Ontario Canada
| | - Bobby Yanagawa
- Division of Cardiac Surgery, St. Michael's Hospital University of Toronto Toronto Ontario Canada
| | - Makoto Hibino
- Division of Cardiac Surgery, St. Michael's Hospital University of Toronto Toronto Ontario Canada
- Division of Cardiac Surgery, Harrington Heart and Vascular Institute University Hospitals Cleveland Medical Center Cleveland Ohio USA
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14
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Sá MP, Sun T, Fatehi Hassanabad A, Awad AK, Van den Eynde J, Malin JH, Sicouri S, Torregrossa G, Ruhparwar A, Weymann A, Ramlawi B. Complete transcatheter versus complete surgical treatment in patients with aortic valve stenosis and concomitant coronary artery disease: Study‐level meta‐analysis with reconstructed time‐to‐event data. J Card Surg 2022; 37:2072-2083. [DOI: 10.1111/jocs.16511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/26/2022] [Accepted: 03/05/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Michel Pompeu Sá
- Department of Cardiothoracic Surgery Lankenau Heart Institute, Lankenau Medical Center, Main Line Health Wynnewood Pennsylvania USA
- Department of Cardiothoracic Surgery Research Lankenau Institute for Medical Research Wynnewood Pennsylvania USA
| | - Tian Sun
- Department of Cardiothoracic Surgery Lankenau Heart Institute, Lankenau Medical Center, Main Line Health Wynnewood Pennsylvania USA
| | - Ali Fatehi Hassanabad
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute Cumming School of Medicine, University of Calgary Calgary Alberta Canada
| | - Ahmed K. Awad
- Faculty of Medicine, Ain Shams University Cairo Egypt
| | - Jef Van den Eynde
- Department of Cardiovascular Sciences KU Leuven Leuven Belgium
- Helen B. Taussig Heart Center The Johns Hopkins Hospital and School of Medicine Baltimore Maryland USA
| | - John H. Malin
- Philadelphia College of Osteopathic Medicine Bala Cynwyd Pennsylvania USA
| | - Serge Sicouri
- Department of Cardiothoracic Surgery Research Lankenau Institute for Medical Research Wynnewood Pennsylvania USA
| | - Gianluca Torregrossa
- Department of Cardiothoracic Surgery Lankenau Heart Institute, Lankenau Medical Center, Main Line Health Wynnewood Pennsylvania USA
- Department of Cardiothoracic Surgery Research Lankenau Institute for Medical Research Wynnewood Pennsylvania USA
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen University Hospital of Essen, University Duisburg‐Essen Essen Germany
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen University Hospital of Essen, University Duisburg‐Essen Essen Germany
| | - Basel Ramlawi
- Department of Cardiothoracic Surgery Lankenau Heart Institute, Lankenau Medical Center, Main Line Health Wynnewood Pennsylvania USA
- Department of Cardiothoracic Surgery Research Lankenau Institute for Medical Research Wynnewood Pennsylvania USA
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15
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Song Y, Qu C, Jiang B, Wang Y. Clinical analysis of coronary artery bypass grafting and concurrent cardiac valve surgery in elderly patients. Asian J Surg 2021; 45:533-534. [PMID: 34649794 DOI: 10.1016/j.asjsur.2021.09.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 08/26/2021] [Accepted: 09/20/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE This study aimed to investigate the clinical effects and perioperative treatment experience of elderly patients with valvular heart disease combined with coronary heart disease undergoing cardiac valve surgery (CVS) and coronary artery bypass grafting (CABG) concurrently. METHODS Seventy-eight patients with heart valve disease and coronary heart disease, aged over 65 and who underwent CVS and CABG concurrently between January 2016 and December 2020, were enrolled in this study. The clinical indexes related to cardiac function before and after surgery, early postoperative complications, and prognosis were analyzed retrospectively to explore the clinical effects and perioperative treatment experience of elderly patients undergoing these two procedures concurrently. RESULTS All patients were reexamined by echocardiography one month after surgery. The results showed that the left ventricular end-diastolic dimension, N-terminal pro-B-type natriuretic peptide levels, cardiothoracic ratio, and troponin-I levels were significantly lower than before surgery, and the differences were statistically significant (P < 0.05). The echocardiography revealed that the left ventricular end-diastolic volume, left ventricular ejection fraction, and left ventricular fractional shortening were larger than before surgery, and these differences were statistically significant (P < 0.05). CONCLUSION It is feasible and effective for elderly patients to undergo CVS and CABG concurrently. Perioperative management can reduce mortality, achieving good clinical effects.
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Affiliation(s)
- Yanyan Song
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Chengliang Qu
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Bo Jiang
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Yun Wang
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, 750004, China.
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16
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Dimagli A, Sinha S, Caputo M, Angelini GD, Benedetto U. Trend in morbidity and mortality in surgical aortic valve replacement: a retrospective, observational, single-centre study. Interact Cardiovasc Thorac Surg 2021; 31:796-802. [PMID: 33150396 DOI: 10.1093/icvts/ivaa189] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 07/06/2020] [Accepted: 07/28/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Continuous improvement in the management of patients undergoing surgical aortic valve replacement (SAVR) may have considerably enhanced surgical outcomes including in-hospital mortality and perioperative complications. We aimed to analyse in-hospital mortality and morbidity trends in patients undergoing SAVR in a single centre to provide insights for future benchmarking for transcatheter aortic valve implantation indications. METHODS This was a retrospective study of prospectively collected data from patients undergoing either isolated SAVR or combined with coronary artery bypass grafting (CABG) at the Bristol Heart Institute, UK, from January 2000 to December 2017. Baseline characteristics were extracted and analysed across 3 different eras (2000-2005, 2006-2011 and 2012-2017). Risk-adjusted time trend was obtained from univariate and multivariate logistic regression including all baseline characteristics. RESULTS A total of 2719 patients (63.2%) underwent isolated SAVR, and 1581 (36.8%) underwent combined CABG and SAVR during the study period. For patients undergoing SAVR, in-hospital mortality decreased from 2.9% in 2000-2005 to 0.7% in 2012-2017 (risk-adjusted time trend 0.0001). Hospital mortality in patients aged 75-79 and ≥80 years decreased from 5.6% and 5.3% to 0.4% and 2.2%, respectively. Mortality after combined SAVR and CABG did not significantly decrease (from 3.9% in 2000-2005 to 3.5% in 2012-2017; risk-adjusted time trend = 0.62). However, in patients aged ≥80 years, index hospitalization mortality showed a decreasing non-significant trend from 9.8% to 4.8%. CONCLUSIONS Our findings support the hypothesis that mortality and morbidity rates following SAVR have significantly improved over the years, including for patients at high risk.
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Affiliation(s)
| | - Shubhra Sinha
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Massimo Caputo
- Bristol Heart Institute, University of Bristol, Bristol, UK
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17
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Abugroun A, Osman M, Awadalla S, Klein LW. Outcomes of Transcatheter Aortic Valve Replacement With Percutaneous Coronary Intervention versus Surgical Aortic Valve Replacement With Coronary Artery Bypass Grafting. Am J Cardiol 2020; 137:83-88. [PMID: 32991856 DOI: 10.1016/j.amjcard.2020.09.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/17/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
We aimed to compare the outcomes of combined surgical aortic valve replacement (SAVR) with coronary artery bypass grafting (CABG) to concurrent transcatheter aortic valve replacement (TAVR) with percutaneous coronary intervention (PCI) in a large U.S. population sample. The National Inpatient Sample was queried for all patients diagnosed with aortic valve stenosis who underwent SAVR with CABG or TAVR with PCI during the years 2016 to 2017. Study outcomes included all-cause in-hospital mortality, acute stroke, pacemaker insertion, vascular complications, major bleeding, acute kidney injury, sepsis, non-home discharge, length of stay and cost. Outcomes of hospitalization were modeled using logistic regression for binary outcomes and generalized linear models for continuous outcomes. Overall, 31,205 patients were included (TAVR + PCI = 2,185, SAVR + CABG = 29,020). In reference to SAVR + CABG, recipients of TAVR + PCI were older with mean age 82 versus 73 years, effect size (d) = 0.9, had higher proportions of females 47.6% versus 26.6%, d = 0.4 and higher prevalence of congestive heart failure and chronic renal failure. On multivariable analysis, TAVR + PCI was associated with lowers odds for mortality adjusted OR: 0.32 (95% CI: 0.17 to 0.62) p = 0.001, lower odds for acute kidney injury, sepsis, non-home discharge, shorter length of stay and higher odds for vascular complications, need for pacemaker insertion and higher cost. The occurrence of stroke was similar between both groups. In conclusion, results from real-world observational data shows less rates of mortality and periprocedural complications in TAVR + PCI compared to SAVR + CABG.
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18
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Tarus A, Tinica G, Bacusca A, Artene B, Popa IV, Burlacu A. Coronary revascularization during treatment of severe aortic stenosis: A meta-analysis of the complete percutaneous approach (PCI plus TAVR) versus the complete surgical approach (CABG plus SAVR). J Card Surg 2020; 35:2009-2016. [PMID: 32667080 DOI: 10.1111/jocs.14814] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/08/2020] [Accepted: 06/18/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The management of patients with coexisting severe aortic stenosis (AS) and coronary artery disease (CAD) is still facing a great deal of uncertainty when it comes to choosing between the entire surgical versus the complete percutaneous approaches, after accurately balancing risks versus outcomes. AIM To evaluate clinical outcomes and mortality of transcatheter aortic valve replacement (TAVR) plus percutaneous coronary intervention (PCI) compared with surgical aortic valve replacement (SAVR) plus coronary arteries bypass grafting (CABG) procedures in patients with concomitant AS and CAD. METHODS Electronic databases of PubMed, EMBASE, and SCOPUS were searched for relevant articles assessing outcome parameters of interest. The study endpoints were the rate of overall myocardial infarction and stroke within 30 days and the rate of 30-day mortality and 2-year mortality between patients with TAVR/PCI and those with SAVR/CABG. RESULTS Random-effect meta-analysis did not reveal any significant difference between 30-day safety outcomes: myocardial infarction (TAVR/PCI vs SAVR/CABG: odds ratio [OR]: 0.52; 95% confidence interval [CI]: 0.20-1.33; I2 = 0%), stroke (TAVR/PCI vs SAVR/CABG: OR: 0.88; 95% CI: 0.45-1.73; I2 = 0%). No significant difference in 30-day mortality (OR: 0.72; 95% CI: 0.43-1.21; I2 = 0%) and 2-year mortality (OR: 1.50; 95% CI: 0.77-2.94; I2 = 81%) rate was noted between patients with TAVR/PCI and those with SAVR/CABG. CONCLUSIONS When comparing the total percutaneous and total surgical treatment, no significant difference in short-term safety outcomes or early and late mortality was observed. More evidence is needed to guide the clinical decision.
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Affiliation(s)
- Andrei Tarus
- Department of Cardiovascular Surgery, Cardiovascular Diseases Institute, Iasi, Romania
| | - Grigore Tinica
- Department of Cardiovascular Surgery, Cardiovascular Diseases Institute, Iasi, Romania.,Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Alberto Bacusca
- Department of Cardiovascular Surgery, Cardiovascular Diseases Institute, Iasi, Romania
| | - Bogdan Artene
- Department of Interventional Cardiology, Cardiovascular Diseases Institute, Iasi, Romania
| | - Iolanda V Popa
- Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Alexandru Burlacu
- Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania.,Department of Interventional Cardiology, Cardiovascular Diseases Institute, Iasi, Romania
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19
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Kotronias RA, Bray JH, Scarsini R, Rajasundaram S, Terentes-Printzios D, De Maria GL, Kharbanda RK, Mamas MA, Bagur R, Banning AP. Transcatheter aortic valve replacement and percutaneous coronary intervention versus surgical aortic valve replacement and coronary artery bypass grafting in patients with severe aortic stenosis and concomitant coronary artery disease: A systematic review and meta-analysis. Catheter Cardiovasc Interv 2020; 96:1113-1125. [PMID: 32662594 DOI: 10.1002/ccd.29110] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/23/2020] [Accepted: 06/05/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES We performed a systematic review and meta-analysis to evaluate the early and midterm outcomes of patients who underwent surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) against patients who had transcatheter aortic valve replacement (TAVR) and percutaneous coronary intervention (PCI). BACKGROUND Contemporary guidelines suggest that surgical or percutaneous revascularization of significant coronary artery disease (CAD) in patients with severe aortic stenosis (AS) is a reasonable strategy. METHODS We conducted a comprehensive search of Medline and Embase to identify studies comparing a percutaneous transcatheter versus a surgical approach. Random effects meta-analyses using the Mantel-Haenszel method were performed to estimate the effect of percutaneous compared surgical strategies using aggregate data. RESULTS Six studies reporting on 1770 participants were included in the meta-analysis. There were no significant differences in effect estimates for early and midterm mortality (OR: 0.78; 95% CI, 0.50-1.20 and OR: 1.09; 95% CI, 0.80-1.49, respectively) or myocardial infarction (OR: 0.52; 95% CI, 0.20-1.33 and OR: 1.34; 95% CI, 0.67-2.65, respectively). No significant difference was shown for peri-procedural stroke (OR: 0.80; 95% CI, 0.35-1.87). A transcatheter approach had a higher rate of major vascular complications (OR: 14.44; 95% CI, 4.42-47.16), but a lower rate of acute kidney injury (OR: 0.41; 95% CI, 0.19-0.91). CONCLUSION Our analysis suggests that a percutaneous transcatheter approach confers similar outcomes compared to a surgical approach in patients with severe AS and CAD. However, our findings are based on low quality studies and should serve as hypothesis generating. In the absence of adequately powered studies yielding high level evidence, individualized decision making should be based on surgical risk assessment.
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Affiliation(s)
- Rafail A Kotronias
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK.,Department of Cardiovascular Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Jonathan H Bray
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Roberto Scarsini
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK.,Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Skanda Rajasundaram
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | | | - Giovanni L De Maria
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Rajesh K Kharbanda
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, UK and Heart Centre, Thomas Jefferson University, Philadelphia, USA
| | - Rodrigo Bagur
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Adrian P Banning
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
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20
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Degenerative Severe Aortic Stenosis and Concomitant Coronary Artery Disease: What Is Changing in the Era of the “Transcatheter Revolution”? Curr Atheroscler Rep 2020; 22:17. [PMID: 32451750 DOI: 10.1007/s11883-020-0835-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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21
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Pirelli L, Patel NC, Scheinerman JS, Brinster DR, Hemli JM, Basman C, Kliger CA. Hybrid Minimally Invasive Approach for Combined Obstructive Coronary Artery Disease and Severe Aortic Stenosis. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2020; 15:131-137. [PMID: 31893954 DOI: 10.1177/1556984519896581] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE There is a high prevalence of concomitant coronary artery disease (CAD) and aortic stenosis (AS), and these conditions can be treated with a variety of invasive and/or percutaneous approaches. The aim of this study is to demonstrate the feasibility, efficacy, and safety of a staged transcatheter aortic valve replacement (TAVR) after a hybrid minimally invasive direct coronary artery bypass surgery (MIDCAB) to treat combined complex CAD and AS. METHODS Six patients with concomitant CAD and severe AS underwent staged treatment of their CAD with MIDCAB and TAVR. All patients had significant complex left main or left anterior descending artery (LAD) stenosis deemed to be not amenable to percutaneous coronary intervention (PCI). RESULTS The average syntax score was 22±8 and the Society of Thoracic Surgeons score for surgical AVR was 8±3%. All patients underwent a single vessel MIDCAB for revascularization of the LAD (three patients required additional PCI for non-LAD disease). Two patients had pre-TAVR balloon aortic valvuloplasty and one patient also required treatment of severe mitral valve regurgitation with percutaneous edge-to-edge repair (the MitraClip). There was no intraprocedural or hospital mortality. No neurological deficits or vascular complications were recorded. CONCLUSIONS A hybrid staged approach for combined complex CAD and severe AS with MIDCAB, PCI, and TAVR is a valid option in high-risk patients. The order and timing of these procedures must be tailored to the patient's clinical symptoms, stability, and severity of disease.
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Affiliation(s)
- Luigi Pirelli
- 5945 Department of Cardiothoracic Surgery, Lenox Hill Heart and Lung, Northwell Health System, New York, NY, USA
| | - Nirav C Patel
- 5945 Department of Cardiothoracic Surgery, Lenox Hill Heart and Lung, Northwell Health System, New York, NY, USA
| | - Jacob S Scheinerman
- 5945 Department of Cardiothoracic Surgery, Lenox Hill Heart and Lung, Northwell Health System, New York, NY, USA
| | - Derek R Brinster
- 5945 Department of Cardiothoracic Surgery, Lenox Hill Heart and Lung, Northwell Health System, New York, NY, USA
| | - Jonathan M Hemli
- 5945 Department of Cardiothoracic Surgery, Lenox Hill Heart and Lung, Northwell Health System, New York, NY, USA
| | - Craig Basman
- 5945 Department of Cardiothoracic Surgery, Lenox Hill Heart and Lung, Northwell Health System, New York, NY, USA
| | - Chad A Kliger
- 5945 Department of Cardiothoracic Surgery, Lenox Hill Heart and Lung, Northwell Health System, New York, NY, USA
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